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Introduction
  • Exposure to
    • hip joint
  • Indications
    • total hip arthroplasty
      • has lower rate of total hip prosthetic dislocations
    • proximal femur fracture

Plane
  • Internervous plane
    • no true internervous plane 
  • Intermuscular plane
    • splits gluteus medius distal to innervation (superior gluteal nerve)
    • vastus lateralis is also split lateral to innervation (femoral nerve)

Preparation
  • Anesthesia
    • options
      • general
      • spinal
  • Position
    • lateral
    • supine

Approach
  • Incision
    • begin 5cm proximal to tip of greater trochanter
    • longitudinal incision centered over tip of greater trochanter and extends down the line of the femur about 8cm
  • Superficial dissection
    • split fascia lata and retract anteriorly to expose tendon of gluteus medius
    • detach fibers of gluteus medius that attach to fascia lata using sharp dissection
  • Deep dissection
    • split fibers of gluteus medius longitudinally starting at middle of greater trochanter 
      • do not extend more than 3-5 cm above greater trochanter to prevent injury to superior gluteal nerve
    • extend incison inferior through the fibers of vastus lateralis
    • develop anterior flap
      • anterior aspect of gluteus medius from anterior greater trochanter with its underlying gluteus minimus
      • anterior part of vastus lateralis
      • requires sharp dissection of muscles off bone or lifting small fleck of bone
    • expose anterior joint capsule 
      • follow dissection anteriorly along greater trochanter and onto femoral neck which leads to capsule
      • gluteus minimus needs to be released from anterior greater trochanter









Structures at Risk
  • Superior gluteal nerve
    • runs between gluteus medius and minimus 3-5 cm above greater trochanter 
    • protect by 
      • limiting proximal incision of gluteus medius
      • putting a stay suture at the apex of gluteal split
    • leads to Trendelenburg gait pattern 
  • Femoral nerve
    • most lateral structure in neurovascular bundle of anterior thigh
    • keep retractors on bone with no soft tissue under to prevent iatrogenic injury

 

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Questions (6)
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(OBQ11.238) A 66-year-old female underwent a surgical procedure 6 weeks ago, and video A demonstrates her gait during ambulation. Based on her gait pattern, which reconstructive procedure did the patient most likely have? Review Topic

QID: 3661
FIGURES:
1

Right total hip arthroplasty through Smith-Petersen approach

3%

(48/1629)

2

Left total hip arthroplasty through Smith-Petersen approach

7%

(109/1629)

3

Left total hip arthroplasty through modified Hardinge approach

72%

(1179/1629)

4

Right total hip arthroplasty through modified Hardinge approach

17%

(273/1629)

5

Left L2-L3 decompression foraminotomy

1%

(10/1629)

Select Answer to see Preferred Response

PREFERRED RESPONSE 3
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(OBQ04.237) Which of the following describes the internervous plane of the direct lateral approach to the hip? Review Topic

QID: 1342
1

Between femoral nerve and superior gluteal nerve

7%

(75/1029)

2

Between superior gluteal nerve and inferior gluteal nerve

2%

(21/1029)

3

Between superior gluteal nerve and sciatic nerve

1%

(15/1029)

4

No true internervous plane as the dissection splits a muscle innervated by the superior gluteal nerve

80%

(821/1029)

5

No true internervous plane as the dissection splits a muscle innervated by the inferior gluteal nerve

9%

(93/1029)

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PREFERRED RESPONSE 4

(OBQ09.256) In a modified Hardinge (lateral) approach to the hip, what structure limits the proximal extent of the gluteus medius split? Review Topic

QID: 3069
1

Superior gluteal nerve

89%

(1050/1174)

2

Inferior gluteal nerve

8%

(94/1174)

3

Pudendal nerve

0%

(2/1174)

4

Corona mortis

1%

(9/1174)

5

Sciatic nerve

1%

(14/1174)

Select Answer to see Preferred Response

PREFERRED RESPONSE 1

(OBQ08.195) Which of the following approaches for total hip arthroplasty is reported to have the lowest prosthetic dislocation rate? Review Topic

QID: 581
1

Posterior approach with posterior soft tissue repair

6%

(90/1630)

2

Anterolateral (Watson Jones)

44%

(725/1630)

3

Direct lateral (Hardinge)

46%

(757/1630)

4

Transtrochanteric

3%

(42/1630)

5

Posterior approach without posterior soft tissue repair

0%

(6/1630)

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PREFERRED RESPONSE 3
EVIDENCE & REFERENCES (8)
Topic COMMENTS (8)
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